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      Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People

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          Introduction:

          Transgender populations have been underrepresented in HIV epidemiologic studies and consequently in HIV prevention, care, and treatment programs. Since 2012, there has been a dramatic increase in research focused on transgender people. Studies highlight the burden of HIV and risk determinants, including intersecting stigmas, as drivers of syndemics among transgender populations. This review synthesizes the most recent global epidemiology of HIV infection and describes current gaps in research and interventions to inform prioritization of HIV research for transgender populations.

          Methods:

          A systematic review was conducted of the medical literature published between January 1, 2012 and November 30, 2015. The data focused on HIV prevalence, determinants of risk, and syndemics among transgender populations.

          Results:

          Estimates varied dramatically by location and subpopulation. Transfeminine individuals have some of the highest concentrated HIV epidemics in the world with laboratory-confirmed prevalence up to 40%. Data were sparse among trans masculine individuals; however, they suggest potential increased risk for trans masculine men who have sex with men (MSM). No prevalence data were available for transgender people across Sub-Saharan Africa or Eastern Europe/Central Asia. Emerging data consistently support the association of syndemic conditions with HIV risk in transgender populations.

          Discussion:

          Addressing syndemic conditions and gender-specific challenges is critical to ensure engagement and retention in HIV prevention by transgender populations. Future research should prioritize: filling knowledge gaps in HIV epidemiology; elucidating how stigma shapes syndemic factors to produce HIV and other deleterious effects on transgender health; and understanding how to effectively implement HIV interventions for transgender people.

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          Most cited references 73

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          Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline.

          The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.
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            Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study.

            We examined relationships between social determinants of health and experiences of transgender-related discrimination reported by transgender people in Virginia. In 2005 through 2006, 387 self-identified transgender people completed a statewide health needs assessment; 350 who completed eligibility questions were included in this examination of factors associated with experiences of discrimination in health care, employment, or housing. We fit multivariate logistic regression models using generalized estimating equations to adjust for survey modality (online vs paper). Of participants, 41% (n = 143) reported experiences of transgender-related discrimination. Factors associated with transgender-related discrimination were geographic context, gender (female-to male spectrum vs male-to-female spectrum), low socioeconomic status, being a racial/ethnic minority, not having health insurance, gender transition indicators (younger age at first transgender awareness), health care needed but unable to be obtained (hormone therapy and mental health services), history of violence (sexual and physical), substance use health behaviors (tobacco and alcohol), and interpersonal factors (family support and community connectedness). Findings suggest that transgender Virginians experience widespread discrimination in health care, employment, and housing. Multilevel interventions are needed for transgender populations, including legal protections and training for health care providers.
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              Transgender health in Massachusetts: results from a household probability sample of adults.

              Despite higher rates of unemployment and poverty among transgender adults (n = 131; 0.5% weighted) than among nontransgender adults (n = 28,045) in our population-based Massachusetts household sample, few health differences were observed between transgender and nontransgender adults. Transgender adults who are stably housed and participated in a telephone health survey may represent the healthiest segment of the transgender population. Our findings demonstrate a need for diverse sampling approaches to monitor transgender health, including adding transgender measures to population-based surveys, and further highlight economic inequities that warrant intervention.
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                Author and article information

                Journal
                J Acquir Immune Defic Syndr
                J. Acquir. Immune Defic. Syndr
                qai
                Journal of Acquired Immune Deficiency Syndromes (1999)
                JAIDS Journal of Acquired Immune Deficiency Syndromes
                1525-4135
                1944-7884
                15 August 2016
                18 July 2016
                : 72
                : Suppl 3
                : S210-S219
                Affiliations
                [* ]Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
                []Department of Epidemiology and Biostatistics, Western University, London, Canada;
                []U.S. Department of Health and Human Services, Health Resources and Services Administration, Rockville, Maryland; and
                [§ ]Boston Children's Hospital/Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA.
                Author notes
                Correspondence to: Tonia Poteat, PhD, MPH, PA-C, 615 North Wolfe Street, E7138, Baltimore, MD 21205 (e-mail: tpoteat@ 123456jhu.edu ).
                Article
                QAIV16885 00002
                10.1097/QAI.0000000000001087
                4969059
                27429185
                Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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